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                                                    U.S. Department of Health and Human Services No. 385, September 2012

AHRQ-funded medical liability and patient safety initiative
shows promise for reducing patient harm, lawsuits, and costs

Many medical students believe that       had done what is called a syringe
if they study hard in medical            swap, where I had given the patient
school, train with the best              the wrong medication. It had an
physicians, and perfect their skills,    absolutely profound effect on the
they will never make a mistake. At       patient, who almost went into
least that’s what Timothy                complete respiratory arrest. It was
McDonald, M.D., J.D., chief safety       incredibly difficult just to steady
and risk officer for health affairs at   my hands and try to take care of
the University of Illinois Hospital      her. And everything you could
and Health Sciences System               possibly imagine was going
(UIHHSS), thought. When he did           through my head.”                       An operating room team works together during
                                                                                 a simulated emergency c-section.
make a mistake, it was devastating.      The reality is that despite health
“The first time I made a mistake, I      care providers’ dedication and best     in the past, according to Dr.
was horrified and terrified all at the   efforts, an alarming number of          McDonald.
same time. It was so clear to me         patients are harmed by medical
when it happened. I had just started     mistakes in the health care system      The approach at UIHHSS is called
my anesthesiology residency and I        and far too many die prematurely        the Seven Pillars and includes:
                                         as a result. Michelle Malizzo           (1) patient safety incident
                                         Ballog, a young mother, was one of      reporting, (2) investigation of the
 Highlights                                                                      event, (3) communication and
                                         them. In 2008, she died of cardiac
 Topics                                  arrest on the operating table due to    disclosure to the patient, (4)
 Patient Safety and Quality        6     an error in monitoring her sedation.    apology and remediation, including
                                         When her family asked how this          waivers of hospital and physician
 Chronic Disease                   8
                                         could have happened, officials at       fees, (5) system process and
 Health Care Costs and Financing   10                                            performance improvement, (6) data
 Elderly Health and Long-Term Care 11
                                         UIHHSS in Chicago did not defer
                                         the question to their lawyers.          tracking and performance
 Adolescent/Child Health           13                                            evaluation, and (7) education and
 Health Information Technology     15    Instead, they investigated the source   training of staff.
                                         of the problem, told the truth and
 Disparities/Minority Health       17
                                         shared the facts, apologized,           UIHHSS’s Seven Pillars Program,
 Comparative Effectiveness         18    accepted accountability, and            begun in 2006 and led by Dr.
                                         provided a financial settlement for     McDonald, is being expanded to
 Regular Features
                                         Ms. Ballog’s young children. They       nine other Chicago-area hospitals
 From the Director                 2     also changed their sedation             as part of a 3-year demonstration
 Agency News and Notes             19    monitoring and anesthesia               project funded in June 2010 under
 Announcements                     19    scheduling processes. This is a total   AHRQ’s Medical Liability and
 Research Briefs                   21    turnaround from the “deny and                             continued on page 3
                                         defend” response to medical errors
From the Director
                       The seven                patient safety events to prevent          hospital system’s medical
                       demonstration            future errors, and fairly and quickly     malpractice premium for FY 2013,
                       projects that            compensate patients who have been         and $3 million in annual savings to
                       are part of              harmed by errors.                         payers, including Medicare and
                       AHRQ’s                   Like all the projects, the ones           Medicaid.
                       Medical                  discussed in this month’s cover           The Fairview Health Services
                       Liability                story have made great strides. The        project to reduce preventable birth-
                       Reform and               Seven Pillars Program first and           related injuries and related
                       Patient Safety           foremost seeks to prevent patient         malpractice claims demonstrates the
                       Initiative have          harm by reporting—and                     value of best practices such as
the potential to transform how our              correcting—flaws in processes that        checklists, communications
nation’s health care system handles             can undercut the work of the most         techniques, teamwork, and
medical liability. These projects are           dedicated clinicians. Second, the         simulation exercises for reducing
building evidence that alternative              environment fostered by                   medical errors. The result has been
approaches to traditional medical               communication and disclosure              a 74 percent reduction in
liability, linked with different                builds respect and trust, which           preventable birth trauma to full-
responses when patient harms do                 figure prominently in the well-being      term newborns, a 38 percent
occur, can improve patient safety,              of patients and physicians. Third,        reduction in preventable neonatal
reduce malpractice suits and                    the Seven Pillars process establishes     intensive care unit admissions of
premiums, reduce the costs of                   and reinforces a culture of learning,     full-term babies, and a 12 percent
defensive medicine, and fairly                  especially among medical residents        reduction in the rate of birth-related
compensate patients and families                who have previously had few               maternal complications at term.
who have been harmed my medical                 opportunities to identify and learn
errors.                                                                                   Finally, the judge-directed
                                                from patient safety events.               negotiation program of the New
Rather than the old approach of                 The result at the University of           York State Unified Court System
“deny and defend,” these projects               Illinois is a 40 to 50 percent            has begun to shift the dynamic of
focus on finding ways to reduce                 reduction in claims and lawsuits per      civil medical malpractice actions
harm before it leads to a lawsuit,              quarter compared to 6 or 7 years          from an attorney-driven process to a
increase transparency, learn from               ago, a 22 percent reduction in the        judge-managed process. The 200
                                                                                          cases that have gone through the
    Research Activities is a digest of research findings that have been produced with     program have shown substantial
    support from the Agency for Healthcare Research and Quality. Research Activities is   savings in time and money from
    published by AHRQ’s Office of Communications and Knowledge Transfer. The
                                                                                          traditional litigation.
    information in Research Activities is intended to contribute to the policymaking
    process, not to make policy. The views expressed herein do not necessarily            I am very heartened by the progress
    represent the views or policies of the Agency for Healthcare Research and Quality,    made by all the demonstration
    the Public Health Service, or the Department of Health and Human Services. For        projects. I am also encouraged by
    further information, contact:
                                                                                          the many hospitals that are
    AHRQ                                        Kevin Blanchet                            interested in replicating these
    Office of Communications                    David I. Lewin                            innovative programs.
      and Knowledge Transfer                    Kathryn McKay
    540 Gaither Road                            Mark W. Stanton
    Rockville, MD 20850                         Contributing Editors
    (301) 427-1360                              Joel Boches                               Carolyn Clancy, M.D.
                                                Design and Production
    Gail S. Makulowich
    Managing Editor                             Farah Englert
                                                Media Inquiries

2     Number 385, September 2012                                                         
Medical liability                         and its 24-hour/7-day hotline.           comfortable reporting things that
continued from page 1                     Recently the head of the hospital’s      they see and are not as fearful that
Patient Safety Initiative. It is one of   risk management team was out of          shame and blame is going to kick
7 demonstration grants, 13 1-year         the hospital and staffing the patient    in,” says Dr. McDonald.
planning grants, and an evaluation        safety hotline via a pager. “We had      The Seven Pillars Program focuses
contract funded by AHRQ.                  a patient go into cardiac arrest in a    on rectifying system problems that
The goal of the demonstration             part of our hospital where that          lead to most errors, rather than
projects, a few of which are              almost never happens, and the            judging and blaming individuals.
discussed in this article, is to          person helping that patient had          As a result, more health care
improve the quality of care and           never even seen a cardiac arrest,”       professionals are reporting safety
patient safety, compensate patients       recounts Dr. McDonald. “They             problems, allowing them to be
fairly and expeditiously when they        called a code, and the team              resolved. And when harm from
are harmed, reduce liability              responded appropriately. The             errors does occur, apologies are
premiums and the costs associated         hotline call allowed us to get the       accompanied by remediation and a
with defensive medicine, and              right people onsite to both support      commitment to improve, as well as
reduce the number of malpractice          the patient and family through this      a waiver of fees for inappropriate
suits filed in the first place. The       outcome…, but also help the care         care. Once the hospital has
projects focus on a number of             professional who was distraught.         determined that a medical error has
areas, including improving                The whole thing was kicked into          harmed the patient, the patient is
communication with patients,              play in 15 minutes even though the       given a card that exempts them
preventing harm through best              risk manager was out of the              from paying all fees at UIHHSS
practices, and providing alternative      hospital.”                               and that can also be used to cover
methods of dispute resolution.            The number of hotline calls has          all related costs if they go to a
                                          soared from 40 calls a year to 500       different hospital.
                                          or 600 calls a year, or about 10 to      As a result, UIHHSS has shown:
Improving communication with              15 calls a week, according to Dr.
patients                                  McDonald. “A lot of time they need       • At least a 40 to 50 percent
Improving communication with              our help to prevent something from         reduction in claims and lawsuits
patients is critical to maintaining       happening, or getting us there may         per quarter compared with 6 or 7
patient trust and avoiding lawsuits.      help diffuse a situation or help with      years ago
In fact, a June 2012 Health Affairs       conflict management or any clinical      • The medical malpractice
article by Dwight Golann, J.D., of        situation where they want help right       premium for FY 2013 for
Suffolk University Law School,            away,” he says. “There’s no doubt          UIHHSS is 22 percent ($10
shows that a large percentage of          that we’re able to prevent errors this     million) less than the $42 million
lawsuits get dropped once both            way. And importantly, it allows us         high mark 4 years ago before the
parties share all the information.        to provide emotional support.”             impact of the Seven Pillars
“To me, that’s critical,” says Dr.                                                   Program
McDonald. “That’s the biggest
point of the Seven Pillars                                                         • $3 million in annual savings to
                                           “There’s no doubt that we’re              payers, including Medicare and
[Program]—to provide immediate
                                           able to prevent errors this               Medicaid, from waiver of all
sharing of information so people
don’t feel they have to sue you just       way. And importantly, it                  hospital and professional fees for
to get that information and then           allows us to provide                      inappropriate care cases, and in
drop the suit later after spending                                                   copay savings to patients
                                           emotional support.”
lots of money on both sides.”                                                      • Substantially reduced costs
Once an incident occurs, the                                                         associated with the practice of
communication and emotional               Reports of safety incidents have           defensive medicine compared
support for both patients and             also risen from 2,000 to nearly            with other area hospitals not
families and caregivers gets              9,000 at UIHHSS over the last              participating in the project
jumpstarted immediately with the          several years. “It is a great measure                   continued on page 4
UIHHSS crisis management team             of culture when people are

                                                                     Number 385, September 2012     3
Medical liability                        hospitals in several States              simulations prior to this event. The
continued from page 3                    participating in the demonstration       team went into action quickly, and
• Significantly reduced time and         project.                                 the baby did well.
  costs associated with malpractice      “The biggest problem we see is that      Checklists are also important. One
  litigation                             people on the labor and delivery         example is the checklist for elective
• Identification and resolution of       unit don’t use closed-loop               induction of labor. The first thing
  unanticipated outcomes of care,        communication,” says Dr. Davis.          on the checklist is to confirm that
  which are not always due to poor       “It’s like what fast food restaurants    the pregnancy is at least 39 weeks,
  care.                                  do when they call back your order.       by doing a cervical exam and
Dr. McDonald wants the next              You then acknowledge that they got       measuring cervical dilation. This
generation of health care                the order right.”                        confirmation is needed to prevent
professionals to have a more                                                      harm before starting a medication
realistic approach to medical errors                                              that starts labor contractions too
and learn how to cope with them.           “The biggest problem we see            quickly, which can lead to a baby
His team works to educate medical          is that people on the labor            with slowed respiration. By using
students and resident physicians,                                                 the checklist, health care
                                           and delivery unit don’t use
who he says are very energized                                                    professionals know to monitor the
                                           closed-loop communication.”            contractions and follow other steps
about the Seven Pillars and its
“principled approach” to patient                                                  to help ensure that the baby is
harm.                                    Davis says that often doctors say        healthy. Since the project began,
                                         the order aloud, but nurses or other     Fairview’s six hospitals have seen a:
                                         team members don’t always affirm         • 74 percent reduction in
Preventing harm through best             that they heard it. The result is that     preventable birth trauma to full-
practices                                either no one or several people will       term newborns, preventing 30
A project to reduce preventable          carry out the same order. “So              cases of trauma over 4 years
birth-related injuries and related       communication ends up being a big          (birth trauma accounts for the
malpractice claims at Fairview           part of making mistakes. That’s            biggest payouts against
Health Services, a health system of      where AHRQ’s TeamSTEPPS®                   obstetrician defendants)
hospitals and clinics in Minnesota,      comes in with its communications         • 38 percent reduction in
is led by Stanley Davis, M.D.,           techniques,” says Dr. Davis.               preventable neonatal intensive
medical director for simulation and                                                 care unit admissions of full-term
teamwork at Fairview. Birth-related      Simulation of high-risk situations,
                                         such as fetal distress, includes           babies over 4 years
injuries typically result from failure
to recognize an infant in distress,      communication techniques,                • 12 percent reduction in the rate
initiate a timely cesarean birth, or     identification of each person’s role,      of preventable birth-related
properly resuscitate a baby in           and course of action. “When you            maternal complications at term,
distress, as well as inappropriate       simulate something like that and           preventing 172 cases of birth-
use of labor-inducing drugs and          videotape it, people can see how to        related maternal complications
inappropriate use of vacuum or           correct problems and work better in        over 4 years.
forceps during delivery.                 those situations,” notes Dr. Davis.

The Fairview project uses perinatal      Fairview’s simulation exercises have     Alternative resolution of
best practices, including checklists,    been effective. For example,
techniques to improve                    benefits of practicing kicked in
                                         when a nurse manager’s daughter          To reduce the cost of medical
communication, teamwork training                                                  malpractice in New York’s courts
for health care providers, and use of    came into the emergency
                                         department with a prolapsed              and mediate fair compensation for
health care simulation of high-risk                                               patients injured due to medical
clinical situations. With AHRQ           umbilical cord, which can be
                                         compressed, cutting off the baby’s       errors, the New York State Unified
funding, Fairview expanded its                                                    Court System began a judge-
program from 2 to 6 of its               blood supply. An emergency c-
hospitals, with a total of 14            section was needed, and the team
                                                                                                 continued on page 5
                                         had done c-sections in the

4   Number 385, September 2012                                                    
Medical liability                        medical background, but they do        program says Susan Senecal, R.N.,
continued from page 4                    have to have some understanding        M.B.A., project director for the
directed negotiation program in          about the kinds of medical issues      New York State Patient Safety and
select areas of New York City in         that may come up in these cases,”      Medical Liability Reform
2004. As part of an AHRQ                 says Judge Kluger. “Our training       Demonstration Project. She
demonstration grant, the existing        was quite extensive. Lawyers and       manages, directs, and coordinates
program was expanded and coupled         doctors who are experts in the field   activities of the project partners.
with a new hospital early disclosure     addressed medical issues the judges    The model uses a checklist that
and settlement model under the           might see, as well as settlement       covers three areas: awareness,
direction of Judge Judy Harris           skills and mediation skills.”          investigation, and resolution.
Kluger, chief of policy and              This program has begun to shift the    Once there is an event, whether it is
planning for New York State              dynamic of civil medical               a medical error or a serious known
Courts. Key stakeholders are             malpractice actions from an            complication of care (for example,
involved in the program through a        attorney-driven process to a judge-    return to the operating room or an
consortium of five major teaching        managed process, and does not          unanticipated colostomy following
hospitals in New York City, the          require any changes in the law. The    surgery), a person is assigned to
New York State Department of             goal of the program is to reach a      coordinate the investigation of the
Health, and New York City medical        fair and expeditious resolution in     patient’s care experience. There is
liability insurers.                      significantly less time than under     an initial discussion with the patient
The intial focus of the project          the previous system, where             generally within 24 hours of the
involved the New York Unified            resolution could take 4 to 5 years.    event by the physician, and the risk
Court system. If a lawsuit is filed      “We’ve saved time and money by         manager is notified. Following the
naming one of the participating          closely managing these cases from      investigation, the conclusions are
grant hospitals as a defendant, the      the outset and, whenever possible,     communicated to the patient—
case is sent to a judge with             limiting the number of costly          whether there was an error or rather
specialized training. The judge          depositions and the need to retain     a complication related to the
supervises the entire process,           expert witnesses in preparation for    underlying disease, and not through
beginning with the very first            trial,” explains Judge Kluger.         fault of the patient’s hospital or the
appearance before the court. This        “That’s the goal. The earlier the      practitioner.
judge takes an active role in setting    case is resolved, the lower the        These swift investigations can
regular case conferences,                litigation costs.”                     uncover process-of-care areas that
monitoring discovery, and                                                       need improvement, preventing them
establishing a schedule for pretrial                                            from happening again, and thus
activity. Additionally, while the case    “That’s the goal. The earlier
                                                                                improving patient safety. They also
is pending, the court will convene        the case is resolved, the lower       enable the patient to receive
the parties to discuss the case and,      the litigation costs.”                information about what happened
if appropriate, help to broker a                                                to them.
settlement (though the judge does
not impose a settlement amount).                                                “The communication and closure
                                         AHRQ funding connected the court       with the patient in and of itself is
The project has trained about 50         project to a new hospital early        the resolution in most of our cases,”
judges from around the State to          disclosure and settlement model.
mediate these cases in New York          This model is essentially a                           continued on page 6
courts. “The judges don’t need a         communication and resolution

 Note: Only items marked with a single (*) asterisk are available from the AHRQ Clearinghouse. See the back
 cover of Research Activities for ordering information. Consult a reference librarian for information on obtaining
 copies of articles not marked with an asterisk.

                                                                  Number 385, September 2012   5
Medical liability                         that, and ensuring that the patient         is expected to increase as more
continued from page 5                     receives fair and quick                     judges are trained, and the initiative
says Ms. Senecal. “It’s not to say,       compensation where there was                is fully implemented in other parts
`Okay, here’s x amount of dollars.        medical injury due to an error.”            of New York.
Will that prevent you from filing a       She agrees with Dr. McDonald, that          What has been the response of
lawsuit?’ The resolution part is          often it is the pursuit of information      hospitals and families to this
identifying what happened and             about their care that drives patients       approach? Says Judge Kluger,
making sure the patient understands       to file lawsuits. The hospitals’ early      “We’ve had very positive feedback
                                          disclosure and settlement programs          from both sides, especially once
                                          aim to avoid that. But sometimes,           hospitals and families understand
“The resolution part is
                                          says Ms. Senecal, people just shut          what is involved—that ultimately
identifying what happened                 down when something tragic                  the goal is to get to an earlier
and making sure the patient               happens and don’t hear what they            resolution that is fair to both sides.”
understands that, and ensuring            are being told, so the hospital             I GM
                                          cannot resolve the situation. That’s
that the patients receive fair                                                        Editor’s note: For details on
                                          when the case goes to the courts.
and quick compensation                                                                AHRQ’s medical malpractice and
                                          To date, more than 200 cases have           patient safety initiative, go to
where there was medical injury            gone through the judge-directed   
due to an error.”                         negotiations program. This number

Patient Safety and Quality

A five-point checklist can help public report sponsors avoid misclassifying
the performance of health care providers
A new study concludes that a five-point checklist can         error. The third checklist point is to use composite
help public report sponsors avoid misclassifying the          scores appropriately, for example, clarifying that the
performance of health care providers. This                    provider with a high composite rating could have a
misclassification can lead to lower quality, greater          great spread among the individual scores.
waste, or patient harm in health care, note RAND              Checklist point four is to perform sensitivity analyses
researchers. They believe that by publicly explaining         to ensure that choosing alternate methods would not
how they addressed the five points in the checklist,          create large changes in the performance scores. The
report sponsors can give performance reports greater          fifth checklist point is to measure the effects of
methodological transparency and improve the chances           reporting to verify that the goal of the public report is
that such reports will give rise to better, more efficient    being met, whether to help patients choose better
care. The checklist highlights key methodological             providers or motivate providers to make quality
options for report sponsors to consider in creating a         improvements. This study
report and helps report users decide if they trust the        was funded by the Agency
information in the report.                                    for Healthcare Research and
The first point includes measuring and addressing             Quality (Contract No. 290-
systematic misclassification, such as reporting higher        07-10022).
mortality rates for patients of providers treating an         More details are in “A five-
older population than for patients of providers treating      point checklist to help
a younger population. Checklist point two focuses on          performance reports
measuring and addressing random misclassification,            incentivize improvement and
which can occur when there is little provider-to-
provider variation in true performance (e.g., if it is                          continued on page 7
uniformly high) or when there is high measurement

6   Number 385, September 2012                                                         
Five-point checklist                                        Editor’s Note: Drs. Friedberg and Damberg were
continued from page 6                                       funded by AHRQ to develop a more detailed User’s
effectively guide patients,” by Mark W. Friedberg,          Guide on this topic, which is available at
M.D., M.P.P., and Cheryl L. Damberg, Ph.D., M.P.H., in
the March 2012 Health Affairs 31(3), pp.612-618. I

 Hospital volume does not predict mortality for patients undergoing lung
 cancer surgery
 Previous studies have linked better     Healthcare Research and Quality       contribution of volume was a
 outcomes from lung cancer               (AHRQ) and is the largest, all-       minimal predictor of mortality
 surgery and high hospital volume        payer inpatient database available    compared to a patient’s age and
 of such surgeries. However, these       in the United States. Hospital        coexisting disease. The
 findings remain controversial. A        volume of lung surgery was            researchers conclude that hospital
 new study, using three different        measured using three different        lung cancer surgery volume should
 methods to measure hospital             methods, including the most           not be used as a proxy measure for
 volume, sheds new light on the          commonly used weighted volume         that hospital’s quality of surgery.
 topic. It finds that the way hospital   stratified into quintiles.            The study was supported in part by
 volume is defined determines any        In two of the three methods, there    AHRQ (HS18049, HS17693).
 impact on mortality and that            was no significant association        See “The relationship between
 overall, a hospital’s volume of lung    between hospital procedure            hospital lung cancer resection
 cancer surgery is not a predictor of    volume and in-hospital mortality.     volume and patient mortality risk,”
 patient mortality.                      The researchers did find a            by Benjamin D. Kozower, M.D.,
 Researchers identified 40,460 lung      significant relationship when using   M.P.H., and George J. Stukenborg,
 cancer patients who underwent           the quintile method. In this case,    Ph.D., in the December 2011
 surgery at 436 hospitals from data      the lowest-volume quintile was        Annals of Surgery 254(6), pp.
 in the 2007 Nationwide Inpatient        associated with more than a 350       1032-1037. I KB
 Sample of the Healthcare Cost and       percent increase in mortality
 Utilization Project. This database      compared with the highest-volume
 is maintained by the Agency for         quintile. However, this relative

Distance-based training in spirometry use increases the quality of asthma
Spirometry is a common office test used to diagnose         entirely by distance through the use of a CD-ROM and
asthma and other conditions affecting breathing by          a series of webinars.
measuring how much air you can inhale and exhale, as        The seven practices receiving the intervention had a
well as how fast you can exhale. However, lack of           significantly greater probability of performing
training and feedback for diagnostic spirometry are         acceptable quality spirometry testing sessions than the
major barriers to its successful incorporation into         seven control group practices. Providers participating in
primary care for asthma patients. The good news is that     the intervention had a 2.9 times greater probability of
online spirometry training can improve the quality of       documenting asthma severity during the intervention
spirometry testing and the assessment of asthma             period than the control group. The proportion of
severity at primary care pediatric practices. The           asthma patients labeled as having persistent asthma
researchers developed and evaluated a spirometry            increased from 43 percent to 62 percent among
training and feedback program that they delivered
                                                                                               continued on page 8

                                                                  Number 385, September 2012   7
Spirometry                                                 and support staff. The study was supported by the
continued from page 7                                      Agency for Healthcare Research and Quality (Contract
intervention practices, but it declined from 57 to 50      No. 290-06-00022).
percent among the control practices.                       See “Learning from a distance: Effectiveness of online
The training intervention consisted of two parts: a 70-    spirometry training in improving asthma care,” by
minute 10-module interactive tutorial on a multimedia      James W. Stout, M.D., Karen Smith, M.D., Chuan
CD-ROM, and a series of five hour-long webinars            Zhou, Ph.D., and others in Academic Pediatrics 12,
delivered over 7 months to a combination of providers      pp. 88-95, 2012. I MWS

Chronic Disease

Opioid prescriptions for treating chronic abdominal pain doubled between
1997 and 2008
Although the number of outpatient       Ambulatory Medical Care Survey),       prescriptions were least commonly
visits for chronic abdominal pain       the researchers estimated that there   given to uninsured patients (12
(CAP) declined by almost a fifth        were 14.8 million outpatient visits    percent of the rate for privately
from 1997–1998 to 2006–2008,            (2,464 per 100,000 population) for     insured patients) and blacks (34
visits during which an opioid was       CAP from 1997 through 1999,            percent of the rate for whites). The
prescribed more than doubled,           which decreased by 17.6 percent (to    researchers call for more studies to
according to a new study. CAP is a      12.2 million outpatients visits, or    better understand the reasons for
common reason for outpatient            1,863 per 100,000 population) for      and consequences of these trends.
visits, and its management is often     2006 through 2008. Over the same       This study was funded in part by
a challenge for clinicians.             period, the proportion of visits for   the Agency for Healthcare Research
Nevertheless, opioid analgesics         CAP in which the patient received      and Quality (HS19468).
have not been proven effective for      at least one opioid prescription       More details are in “Increasing
treating CAP and have been linked       increased from 5.9 percent during      frequency of opioid prescriptions
to drug misuse and gastrointestinal     1997–1999 to 12.2 percent during       for CAP in US outpatient clinics,”
symptoms, including worsening           2006–2008.                             by Spencer D. Dorn, M.D., M.P.H.,
pain.                                   The likelihood of receiving an         Patrick D. Meek, D.Pharm.,
Based on two national surveys,          opioid prescription was highest for    M.S.P.H., and Nilay D. Shah, Ph.D.,
each conducted a decade apart (the      patients 25 to 50 years old (4.8       in the December 2011 Clinical
National Ambulatory Medical Care        times more likely than for ages 18     Gastroenterology and Hepatology
Survey and the National Hospital        to 24 years). In contrast, opioid      9(12), pp. 1078-1085. I DIL

Response to etanercept for rheumatoid arthritis can be predicted by 12
Decision trees specifically designed for patients with     Data for this study were taken from the Trial of
rheumatoid arthritis for whom etanercept with or           Etanercept and Methotrexate with Radiographic Patient
without methotrexate is newly prescribed now permit        Outcomes (TEMPO). Patients in this trial received 25
researchers to determine in which patients treatment       mg of etanercept twice a week; methotrexate from 7.5
efficacy can be predicted with confidence after only 12    to 20 mg once a week, depending upon persistence of
weeks. These classification and regression trees also      joint pain or swelling; or both drugs. The researchers
identify those patients in whom the likelihood of          developed various decision trees to predict by week 12
achieving low disease activity (LDA) within 1 year of      whether LDA would be achieved at the end of 1 year of
this therapy is indeterminate after only 12 weeks on       therapy.
that regimen.
                                                                                             continued on page 9

8   Number 385, September 2012                                                 
Rheumatoid arthritis                                       remaining 10 to 20 percent of patients required more
continued from page 8                                      time on therapy to establish whether they would
Some 39 percent of patients receiving etanercept alone     respond adequately or should discontinue this
and 60 percent of patients receiving etanercept plus       treatment.
methotrexate achieved LDA at week 52. At week 12,          The study was supported in part by the Agency for
53 percent of patients receiving etanercept were           Healthcare Research and Quality (HS18517).
predicted to achieve LDA, while another 39 percent
were predicted not to do so. Among patients prescribed     See “Predicting low disease activity and remission
etanercept plus methotrexate, 63 percent were predicted    using early treatment response to antitumour necrosis
to achieve LDA and 25 percent were predicted not to        factor therapy in patients with rheumatoid arthritis:
respond. As a result, within 12 weeks of initiating        Exploratory analyses from the TEMPO trial,” by
etanercept with or without methotrexate, success or        Jeffrey R. Curtis, M.D., M.P.H., Shuo Yang, Lang
failure in achieving an outcome of LDA at 52 weeks         Chen, M.D., and others in the Annals of Rheumatology
could be predicted in 80 to 90 percent of patients. The    Diseases 71, pp. 206-212, 2012. I KB

  About three-fourths of patients in the United States estimated to remain
  in HIV care
  Keeping patients with HIV in         States. Three measures of                sex with men (MSM). An initial
  continued care (retention) is        retention were used. One measure         CD4 cell count of 50 cells/µl or
  critical for successful treatment    was the proportion of time not           less (an indicator of more
  outcomes and survival. It may also   spent in a gap of more than 6            advanced disease) was also
  reduce HIV transmission in the       months between successive                associated with a higher retention
  community and lower costs.           outpatient visits. The second            rate. Groups at greater risk for
  Recently, John A. Fleishman,         measure was the proportion of 91-        low retention rates included
  Ph.D., from the Agency for           day quarters during which at least       younger patients, men, blacks,
  Healthcare Research and Quality      1 visit took place. Finally, the third   non-MSM risk groups, and
  and others compared three            measure was the proportion of            individuals with higher initial CD4
  different measures of retention in   years where two or more visits           cell counts.
  a large group of HIV patients.       were separated by at least 90 days.      More details are in “Comparing
  Retention rates ranged from 71       On average, 71 percent of time in        different measures of retention in
  percent to 75 percent. Certain       care was not spent in a gap of           outpatient HIV care,” by Baligh R.
  groups were at an increased risk     more than 6 months. Also, 73             Yehia, M.D., Dr. Fleishman,
  for low retention.                   percent of all quarters had at least     Joshua P. Metlay, M.D., Ph.D., and
  Data were retrieved from the         one patient visit. For the third         others in the June 1, 2012 AIDS
  medical records of 17,425 patients   measure, 75 percent of all years         26(9), pp. 1131-1139. Reprints
  with HIV infection. All were         had at least 2 visits separated by at    (AHRQ Publication No. 12-R064)
  receiving their care at 12 HIV       least 90 days. Retention rates           are available from AHRQ.* I KB
  clinical sites located in various    were highest for women, whites,
  geographic regions of the United     older individuals, and men having

                                                                  Number 385, September 2012    9
Health Care Costs and Financing

 The financial burden from prescription drugs has declined for the
 nonelderly, but remains a problem for some groups
 Although the cost burden of prescription drugs for        percent) and 67.1 million (25.4 percent) lived in
 nonelderly adults grew substantially from 1999            families whose prescription drug expenses accounted
 through 2003, by 2008 the cost burden had fallen          for more than half of their out-of-pocket health
 back to 1999 levels, according to a new study. This       expenses.
 decline demonstrates the success of strategies to lower   Individuals with high drug-cost burden in 2008 varied
 drug costs for consumers, including increased use of      with insurance type—7.5 percent for those with
 generic drugs, note the researchers. However, they        public insurance (down from 11.1 percent in 1999),
 found that the financial burden of prescription drugs     4.5 percent among those with private nongroup (not
 is still high among some groups, notably those with       employer-related) insurance, and 1.2 percent for those
 public insurance and those with low incomes.              with employer-related insurance. The findings were
 Prescription drug burden is calculated in two ways:       based on data from the 1999–2008 Medical
 (1) as out-of-pocket drug costs compared to family        Expenditure Panel Surveys of the Agency for
 income and (2) as the proportion of all out-of-pocket     Healthcare Research and Quality (AHRQ). The
 health care expenses accounted for by prescription        researchers note that these trends suggest that the
 drugs. The researchers found that in 1999, 7.1 million    affordability of prescription drugs under the future
 people (2.9 percent of the United States population)      insurance exchanges will need to be monitored, as
 lived in families that spent more than 10 percent of      will efforts by States to boost copayments under
 their family income on prescription drugs. That same      Medicaid or otherwise restrict drug use to reduce
 year 64.5 million people (26.7 percent of the             public spending. Some of the authors were funded in
 population) lived in families in which prescription       part by AHRQ (HS17695 and HS18657).
 drugs accounted for more than half of all out-of-         More details are in “The financial burden from
 pocket health care spending. These numbers had risen      prescription drugs has declined recently for the
 in 2003 to 10.8 million people (4.3 percent) who had      nonelderly, although it is still high for many,” by
 high drug-cost burden and 85.2 million (33.6 percent)     Walid F. Gellad, M.D., M.P.H., Julie M. Donohue,
 who spent more than half of their out-of pocket health    Ph.D., Xinhua Zhao, Ph.D., and others in the February
 care expenses for prescriptions.                          2012 Health Affairs 31(2), pp. 408-416. I DIL
 By 2008, persons living in families with high drug-
 cost burden had dropped to 8.3 million people (3.1

Differences in the costs of drugs prescribed lead to regional variation in
Medicare Part D drug spending
Regional differences in Medicare       costs of angiotensin-converting-       that differences in the mean
Part D (prescription drug coverage)    enzyme inhibitors (ACEIs) and          adjusted cost for all drugs per
outlays for three classes of drugs     angiotensin-receptor blockers          beneficiary ranged from $2,413 in
reflect geographic variation in the    (ARBs), statins, and selective         the lowest fifth of Medicare
use of brand-name and generic          serotonin reuptake inhibitors          hospital referral regions (HRRs) to
medications in each category rather    (SSRIs) and serotonin–                 $3,008 in the highest fifth.
than the volume of prescriptions.      norepinephrine reuptake inhibitors     Geographic variation in mean costs
That’s the finding of a new study.     (SNRIs), as well as overall            per prescription ($53 vs. $63)
Researchers examined variation in      spending for all drugs. They found
                                                                                            continued on page 11

10   Number 385, September 2012                                               
Medicare Part D                          and SNRIs) showed high correlation        percent random sample of the 2008
continued from page 10                   with prescription prices. If all HHRs     Medicare Denominator files. The
accounted for 76 percent of this         in the four higher quintiles of drug      study was funded in part by grants
difference.                              cost had adopted the branded-to-          from the Agency for Healthcare
Regional differences in per              total prescription ratios of the lowest   Research and Quality (HS17695,
prescription costs explained nearly      quintile, the Medicare program and        HS18721, HS19421).
88 percent of the differences for        its beneficiaries would have saved        More details are in “Sources of
ACEIs and ARBs and 56 percent of         $4.5 billion (10 percent of costs) for    regional variation in Medicare Part
the differences for statins, but only    the year under study. The                 D Drug Spending,” by Julie M.
36 percent for SSRIs and SNRIs.          researchers suggest that reducing         Donohue, Ph.D., Nancy E. Morden,
The ratio of brand-name drugs to         branded-drug use in some regions          M.D., M.P.H., Walid F. Gellad,
total prescriptions (ranging from        through modification of Part D plan       M.D., M.P.H., and others, in the
0.24 to 0.45 overall, 0.24 to 0.55 for   benefits might lower costs without        February 9, 2012 New England
ACEIs and ARBs, 0.29 to 0.60 for         reducing quality of care. Their           Journal of Medicine 366(6), pp.
statins, and 0.15 to 0.51 for SSRIs      findings were based on Medicare           530-538. I DIL
                                         Part D prescription data for a 40

  Elderly Health and Long-Term Care

 Studies link adverse drug interactions to elevated risk for hospitalization
 among the elderly
 The elderly population consumes a disproportionate          SMX/TMP; sulfonylureas and antimicrobial agents;
 share of prescription and over-the-counter drugs            theophylline and ciprofloxacin; and warfarin and
 relative to younger persons. These factors, combined        antimicrobial agents or non-steroidal anti-
 with age-related changes in the ability of the body to      inflammatory drugs.
 process and respond to drugs, make the elderly              The researchers conclude that when the elderly
 population more susceptible to drug interactions. A         receive drug therapy, it should be absolutely necessary
 review of 17 studies that assessed specific drug            for the achievement of well-defined goals. They also
 interactions in elderly patients found that 16 of the       recommend that an evidence-based, high-priority list
 studies reported an elevated risk for hospitalization in    of drug interactions in the elderly be developed and
 older adults associated with drug interactions.             maintained. This study was supported in part by the
 These interactions included angiotensin-converting          Agency for Healthcare Research and Quality
 enzyme (ACE) inhibitors and potassium-sparing               (HS19220, HS17001).
 diuretics; ACE inhibitors or angiotensin receptor           See “Potentially harmful drug-drug interactions in the
 blockers and sulfamethoxazole/trimethoprim                  elderly: A review,” by Lisa E. Hines, Pharm.D. and
 (SMX/TMP); benzodiapines or zolpidem and other              John E. Murphy, Pharm.D. in the American Journal of
 medications; calcium channel blockers and macrolide         Geriatric Pharmacotherapy 9, pp. 364-377, 2011. I
 antibiotics; digoxin and macrolide antibiotics; lithium
 and loop diuretics or ACE inhibitors; phenytoin and

                                                                  Number 385, September 2012   11
Conventional and atypical antipsychotic drugs show differing safety risks
among older nursing home residents
Up to a third of older nursing home     found that users of haloperidol, a       heart attack, cerebrovascular event
residents are treated with              conventional antipsychotic drug,         (stroke or transient ischemic
antipsychotics to help control          were twice as likely to die within       attack), or hip fracture. Of the
behavioral problems. In two studies     180 days of beginning treatment          83,959 nursing home residents
supported by the Agency for             (107 percent increased risk) than        included in the group, 8.9 percent
Healthcare Research and Quality         residents treated with risperidone,      were prescribed a conventional
(HS17918, HS16097), the                 an atypical antipsychotic.               antipsychotic drug and 91.1 percent
researchers found that atypical         Only quetiapine (another atypical        were prescribed an atypical
antipsychotic drugs (such as            antipsychotic) exhibited                 antipsychotic.
risperidone) were associated with       significantly lower 180-day              Based on hospitalizations for the
lower hazard rates than                 mortality (by 19 percent) than           major medical events within 180
conventional antipsychotic drugs        risperidone. The effect of               days of starting antipsychotic
(such as haloperidol) for overall       haloperidol was strongest during         therapy, residents who began taking
death rates and rates of specific       the first 40 days of treatment, and      a conventional antipsychotic
causes of death, excluding cancer.      declined during the rest of the 180-     (haloperidol) were at 37 percent
Similarly, they found that the risk     day period.                              greater risk of developing a serious
of developing cardiac disease, hip      The risperidone–quetiapine               bacterial infection, but had 19
fractures, and infections were lower    difference was also greatest during      percent lower risk of a
for treatment with atypical rather      this initial period. Dose effects were   cerebrovascular event than were
than conventional antipsychotic         the strongest for haloperidol, with      residents who initiated taking an
drugs. However, risks of                mortality risk 84 percent greater for    atypical antipsychotic (risperidone).
cerebrovascular events were lower       high-dose than low-dose therapy.         Residents taking a conventional
for conventional antipsychotic          Similarly, risperidone risk was 35       antipsychotic were at greater risk of
drugs.                                  percent greater for high-dose than       heart attack (by 23 percent), hip
In both studies, the researchers        low-dose therapy.                        fracture (by 27 percent), and
analyzed data on new users of                                                    pneumonia (by 28 percent), but
antipsychotic drugs (haloperidol,                                                these increases were not statistically
aripiprazole, olanzapine, quetiapine,                                            significant. Both the increased risk
risperidone, and ziprasidone)                                                    of serious bacterial infection and
among elderly adults, who were                                                   the decreased risk of
eligible for Medicaid and lived in a                                             cerebrovascular events for nursing
nursing home in 2001–2005. Both                                                  home residents taking haloperidol
studies are briefly described here.                                              were dose-dependent.
                                        Huybrechts, K.F., Schneeweiss,           Comparison of other atypical
Huybrechts, K.F., Gerhard, T.,          S., Gerhard, T., and others.             antipsychotic drugs with
Crystal, S., and others. (2012).        (2012, March). “Comparative              risperidone found only modest
“Differential risk of death in          safety of antipsychotic                  significant differences for
older residents in nursing homes        medications in nursing home              cerebrovascular event risk for
prescribed specific antipsychotic       residents.” Journal of the               residents who began taking
drugs: Population based cohort          American Geriatrics Society 60(3)        olanzapine or quetiapine, but a
study.” British Medical Journal         pp. 420-429.                             significantly reduced risk of serious
344:e977, 12 pp.                        This study examined how the              bacterial infections (by 17 percent)
This study compared the risk of         antipsychotic drugs differed in risk     for those starting quetiapine. I DIL
death in 75,445 elderly nursing         of developing major medical
home residents. The researchers         events—serious bacterial infection,

12   Number 385, September 2012                                                  
Several factors influence completion of chemotherapy in elderly patients
with stage-III colon cancer
Colon cancer is predominantly a disease of those 65        chemotherapy in a shorter period of time after surgery.
years and older. For patients with stage-III colon         Factors associated with completing a full course of
cancer, adjuvant chemotherapy following surgery can        chemotherapy included being younger, male, black, and
reduce cancer recurrence and mortality. A new study        married. Those patients who were older, female, and
found better chemotherapy completion rates among the       white were more likely to discontinue chemotherapy
elderly with this condition than in earlier years, with    than others.
age the most important predictor of initiation and         Compared to patients diagnosed from 1991–1993,
completion of therapy.                                     those diagnosed after 1997 were nearly two times more
The study included data on 12,265 patients with stage-     likely to complete chemotherapy. The study was
III colon cancer who were 65 years of age and older.       supported in part by the Agency for Healthcare
All were diagnosed between 1991 and 2005. Medicare         Research and Quality (HS16743).
claims were analyzed to determine if and when              See “Assessing the initiation and completion of
chemotherapy was initiated and for how long.               adjuvant chemotherapy in a large nationwide and
Overall, 64.4 percent of patients received chemotherapy    population-based cohort of elderly patients with stage-
within 3 months following surgery. Factors associated      III colon cancer,” by Chung-Yuan Hu, Ph.D., George L.
with being more likely to receive chemotherapy             Delclos, M.D., M.P.H., Ph.D., Wenyaw Chan, Ph.D.,
included being male, white, younger, and married.          and Xianglin L. Du, M.B., M.S., Ph.D., in Medical
Younger patients were also more likely to start            Oncology 28, pp. 1062-1074, 2011. I KB

Adolescent/Child Health

No link found between stimulant treatment of youth with ADHD and
cardiovascular problems
Stimulants are widely considered       ADHD with no known                     methylphenidate and mixed salts of
the first-line drug treatment for      cardiovascular risk factors.           amphetamine in a large privately
children and adolescents with          The researchers reviewed the           insured population. Data on service
attention deficit hyperactivity        records of 171,126 patients with       and pharmacy claims came from a
disorder (ADHD), with                  ADHD who were 6 to 21 years of         commercial research database. This
approximately 3.2 percent of youth     age and without known                  study was supported in part by the
in the United States being treated     cardiovascular risk factors. They      Agency for Healthcare Research
with stimulants each year.             found that clinical diagnoses of       and Quality (HS16097).
Stimulants, which increase heart       cardiovascular events and              See “Stimulants and cardiovascular
rate and blood pressure, have          symptoms were rare and not             events in youth with attention-
labeling required by the Food and      associated with stimulant use.         deficit/hyperactivity disorder,” by
Drug Administration that warns of      These findings help to reduce          Mark Olfson, M.D., Cecilia Huang,
the possibility of sudden death from   concerns over the cardiovascular       Ph.D., Tobias Gerhard, Ph.D., and
stimulant use in children and          safety of stimulant therapy for        others in the February 2012 Journal
adolescents with structural cardiac    ADHD in young people without           of the American Academy of Child
abnormalities or other serious heart   known pre-existing risk factors.       & Adolescent Psychiatry 51(2), pp.
problems. However, a new study                                                147-156. I MWS
found no association between           The researchers focused on the
stimulant treatment of youth with      treatment of ADHD with

                                                               Number 385, September 2012   13
 Pediatric visits for ADHD have risen and the condition is increasingly
 being managed by psychiatrists
 Attention deficit hyperactivity disorder (ADHD) is       psychiatrist. By 2010, more than one-third (36
 common among children and adolescents in the             percent) of ADHD-related visits were to psychiatrists,
 United States. Diagnosis from 2003–2007 increased        while the share of ADHD-related visits to
 21.8 percent among children aged 4–17 years, from        pediatricians shrank from 54 to 47 percent. This shift
 7.6 percent to 9.5 percent, representing 5.4 million     toward greater specialist care was not accompanied
 children. Changes in clinical practice guidelines, the   by evidence of an increase in illness severity in
 introduction of new medications such as atomoxetine      treated cases.
 (Strattera®), as well as growing medication-related      Several factors may account for this shift, note the
 concerns, prompted researchers to take a fresh look at   researchers. Advocacy efforts and publicity
 the diagnosis and treatment of ADHD from 2000 to         campaigns may have led to greater public awareness.
 2010.                                                    Also, increased provider knowledge of ADHD from
 During this period, ambulatory visits coded with a       the dissemination of clinical guidelines and
 diagnosis of ADHD increased by two-thirds and            continuing medical education may have led to
 management of these cases by psychiatrists increased,    parents, children, and providers identifying behavioral
 according to a team of Chicago- and Boston-based         and conduct disorders as ADHD. A growing number
 researchers. The number of ADHD-related visits           of medications, as well as marketing and promotion
 increased from 6.2 million in 2000 to 10.4 million in    by pharmaceutical firms, may have also contributed
 2010. As the number of patients being treated            to this trend. This study was supported in part by the
 increased, the percentage receiving stimulants           Agency for Healthcare Research and Quality
 decreased from 98 percent in 2001 to 87 percent in       (HS189960).
 2010. The share of those receiving atomoxetine           See “Trends in attention deficit hyperactivity disorder
 (originally used as an antidepressant) decreased from    ambulatory diagnosis and medical treatment in the
 15 percent when the drug was introduced to 6 percent     United States, 2000–2010,” by Craig F. Garfield,
 in 2010.                                                 M.D., E. Ray Dorsey, M.D., Shu Zhu, M.P.H., and
 In 2000, approximately one fourth (24 percent) of all    others in Academic Pediatrics 12, pp. 110-116, 2012.
 visits in which ADHD was coded were visits to the        I MWS

Study fails to find link between guideline-based emergency treatment for
pediatric asthma and patient outcomes
Adherence to guideline-based          percent moderate, and 9 percent         receipt/nonreceipt process measures
emergency treatment of children       severe asthma acuity), who were         was 84 percent. For the timeliness
with asthma had no significant        seen at one of the 14 study EDs.        measures, 58 percent of those
impact on patient outcome,            They looked at compliance with          children recommended to receive a
according to the first multicenter    five process-of-care measures and       systemic corticosteroid at the ED
study of the topic. The primary       two timeliness measures. Of this        did so within the first hour; and 92
outcome measure was successful        group, 62 percent were successfully     percent of those recommended to
discharge, defined as emergency       discharged from the ED after            receive ED treatment with an
department (ED) discharge without     treatment, 15 percent had either a      inhaled beta-agonist did so in the
an asthma-related return visit or     relapse or ongoing symptoms             first hour.
ongoing symptoms in the               within 2 weeks, and 24 percent          However, adherence to the
subsequent 2 weeks. The               were admitted to the hospital for       guideline process-of-care and
researchers analyzed the care for     care. The composite score for
1,426 patients (58 percent mild, 33   compliance with all five                              continued on page 15

14   Number 385, September 2012                                               
Pediatric asthma                        The researchers attribute this last     More details are in “Multicenter
continued from page 14                  finding to insufficient adjusting for   analysis of quality indicators for
timeliness measures was not             severity of asthma acuity, because      children treated in the emergency
associated with successful ED           patients with more severe asthma        department for asthma,” by Marion
discharge in adjusted models. In        are both more likely to have timely     R. Sills, M.D., M.P.H., Adit A.
these models, the one significant       albuterol medication and more           Ginde, M.D., M.P.H., Sunday Clark,
finding was that timely use of an       likely to be hospitalized. This study   Sc.D., M.P.H., and others in the
inhaled beta-agonist increased the      was funded in part by the Agency        February 2012 Pediatrics 129(2),
odds of hospitalization 4.4-fold.       for Healthcare Research and             pp. e325-e332. I DIL
                                        Quality (HS16418).

 Health Information Technology

 Parental reports more accurate than electronic health records in
 documenting child diet and exercise counseling
Thirty-two percent of children and adolescents between       screening time (92 percent) and physical activity (88
the ages of 2 and 19 are either obese or overweight.         percent). EHRs also had poor specificity (42 percent
Since food intake and physical activity are the primary      and 21 percent, respectively, for screening time and
modifiable determinants of obesity, behavior and             physical activity). EHR documentation may suffer from
lifestyle modification are critical to obesity prevention    information bias, suggest the researchers, because it
and management. Various authorities recommend that           tends to underestimate the discussion of many topics
physicians counsel parents during well-child visits on       related to weight and nutrition and its potential to
diet and physical activity—a practice that varies.           significantly overestimate counseling on certain topics
Reports by parents about diet and exercise counseling        specific to the design of local EHR templates.
of their children by pediatricians is somewhat more          The findings were based on analysis of audiotapes of
accurate than documentation of this counseling in the        the clinical sessions in which 38 physicians and parents
child’s electronic health record (EHR), concludes a new      of 198 children participated and the EHR
study.                                                       documentation of the visits. The study was supported in
A team of researchers led by Ulfat Shaikh, M.D. of the       part by the Agency for Healthcare Research and
University of California, Davis School of Medicine           Quality (HS18567).
compared parental reports given immediately after the        See “Accuracy of parental report and electronic health
office visit to EHR documentation of the visit. The          record documentation as measures of diet and physical
sensitivity of parental report was high (63 to 96            activity counseling,” by Ulfat Shaikh, M.D., Jasmine
percent), but specificity was low (43 to 77 percent)         Nettiksimmons, M.A., Robert A. Bell, Ph.D., and
because of parents’ tendency to overreport counseling.       others in Academic Pediatrics 12, pp. 81-87, 2012. I
The sensitivity of EHR documentation was generally           MWS
low (40 to 53 percent) except for discussion of

Telemedicine dermatology consultations change diagnoses and improve
Telemedicine services continue to       screen. Recently, researchers           in changes in diagnosis and disease
mature as a way to provide patient      compared teledermatology consults       management.
care from a distance, especially for    at a large academic medical center      The study included 1,490 patients
rural areas. Dermatology lends itself   with diagnoses and treatment made       who received a teledermatology
well to telemedicine, since skin        initially by the referring physician.   consultation from a large academic
conditions can be visibly seen on a     In the majority of instances, the       dermatology clinic. Of these, 313
                                        telemedicine consultations resulted
                                                                                              continued on page 16

                                                                 Number 385, September 2012    15
Telemedicine dermatology                either a benign or malignant lesion.   improvement compared to those
continued from page 15                  These telemedicine consultations       with no change. After the first
had 2 or more telemedicine visits.      also led either to the start of or     consultation, each additional
All were referred by primary care       discontinuation of therapy in 67.5     followup telemedicine visit was
providers from 31 facilities across     percent of cases. More than a          associated with double the odds of
California. Research assistants         quarter of cases (26.4 percent)        improvement in clinical outcomes.
reviewed each patient’s medical         resulted in various surgical and       The study was supported in part by
record to see if the teledermatology    other treatment interventions.         the Agency for Healthcare Research
consultation resulted in a change in    Overall 97.7 percent of                and Quality (HS18341).
diagnosis, disease management, and      consultations resulted in changes in   See “Impact of live interactive
clinical outcome.                       disease management. In the group       teledermatology on diagnosis,
A teledermatology consultation          of 313 patients with two or more       disease management, and clinical
resulted in a change in diagnosis in    consultations, 215 of them (68.7       outcomes,” by Sonia Lamel, M.D.,
69.9 percent of cases. The top          percent) experienced an                Cindy J. Chambers, M.D., M.P.H.,
change was from a diagnosis of          improvement in clinical status after   Mondhipa Ratnarathorn, M.D., and
skin infection to diagnosis of a        their teledermatology encounter.       April W. Armstrong, M.D., M.P.H.,
primary inflammatory process.           Those patients with a change in        in the January 2012 Archives of
Other leading changes involved an       diagnosis had nearly two times         Dermatology 148(1), pp. 61-65. I
incorrect primary care diagnosis of     greater odds of clinical               KB

  Drug interaction decision support software has limitations and
  pharmacists’ knowledge of support features is limited
  Clinical decision support features of drug information    their software was updated. The 61 pharmacists
  software include drug-drug interaction (DDI), drug-       interviewed were employed at community
  allergy checking, and other advanced features to          pharmacies, inpatient hospital pharmacies, and
  guide safe medication use. However, a new survey of       “other” pharmacies, including 2 infusion pharmacies,
  61 pharmacists shows that pharmacists have only           1 long-term care pharmacy, and 3 Indian Health
  limited awareness of the many decision support            Service locations.
  features available in their systems.                      They reported using a total of 24 different software
  Of the 61 pharmacists surveyed by University of           vendors for their information systems. It was unclear,
  Arizona researchers, 60 percent reported that their       however, whether pharmacists’ limited awareness of
  DDI decision support systems included                     their systems was a function of pharmacist training
  recommendations for managing drug interactions.           and knowledge or whether there are actual
  Two-thirds of respondents reported that their             deficiencies associated with various pharmacy
  pharmacy’s system permitted the addition of               information systems. The study was supported by the
  medications from other pharmacies and/or over-the-        Agency for Healthcare Research and Quality
  counter products to a patient’s profile. Approximately    (HS19220).
  40 percent of the pharmacists reported that some          See “Pharmacists’ awareness of clinical decision
  drugs entered into the pharmacy computer system           support in pharmacy information systems: An
  were not included in the electronic DDI checking.         exploratory evaluation,” by Lisa E. Hines, Pharm.D.,
  Most pharmacists indicated the presence of other          Kim R. Saverno, R.Ph., B.S. Pharm., Terri L.
  decision support features, such as drug-disease           Warholak, Ph.D., and others in Research in Social
  precautions (78 percent), drug-age precautions (67        and Administrative Pharmacy 7, pp. 359-368, 2011.
  percent), and appropriate dosage alerts (79 percent).     I MWS
  Forty percent of pharmacists did not know how often

16   Number 385, September 2012                                                 
Disparities/Minority Health

Despite more widespread prescribing of antiretroviral therapy for HIV
infection, disparities remain
Although prescription of                 The proportion of HIV-infected          youngest group (18–29 years vs.
antiretroviral therapy (ART) to          patients prescribed ART increased       30–39 and 50 and older), and these
combat HIV disease became more           from 60 percent in 2002 to 80           differences were more pronounced
widespread from 2002 to 2008,            percent in 2008. Among those with       at earlier disease stages. The fact
patients who were female, black, or      two or more CD4 tests of 350            that ART use increased among
younger still had lower ART rates        cells/mm3 or less, the proportion       traditionally disadvantaged groups,
than male, white, or older patients,     increased from 82 percent in 2002       such as women and black patients,
reveals a new study. John A.             to 92 percent in 2008. ART rates        is encouraging and shows that
Fleishman, Ph.D., of the Agency for      were higher for those with lower        improvements in care are possible
Healthcare Research and Quality          CD4 counts (more advanced               for such groups, note the
(AHRQ), and colleagues analyzed          disease), but increased over time for   researchers.
data from the medical records at 13      all CD4 groups.                         More details are in “Disparities in
U.S. sites participating in the                                                  receipt of antiretroviral therapy
Human Immunodeficiency Virus             While ART prescribing rates rose
                                         among all demographic groups,           among HIV-infected adults
Research Network. They assessed                                                  (2002–2008),” by Dr. Fleishman,
ART prescribing for 14,092 patients      racial/ethnic and sex disparities
                                         persisted. For example, ART rates       Baligh R. Yehia, M.D., Richard D.
for each year they were in care.                                                 Moore, and others in the May 2012
They examined ART use as a               were consistently lower for women
                                         than men, and blacks were less          Medical Care 50(5), pp. 419-427.
function of sex, race/ethnicity, HIV                                             Reprints (AHRQ Publication No.
risk group, age, and CD4 history         likely to be prescribed ART than
                                         whites, after adjusting for CD4         12-R065) are available from
(CD4 cell counts are an indicator of                                             AHRQ.* I KB
HIV disease progression).                history. ART use increased for all
                                         age groups, but more slowly for the

Minority-serving hospitals have problems with quality of care and patient
Previous studies have shown              Hospitals with the largest              Overall, the concentration of black
disparities in the quality of care for   percentages of black patients were      patients in a hospital was a
blacks, including higher surgical        large, urban, teaching hospitals.       significant predictor of poor
mortality and complication rates.        Nurses working at these institutions    satisfaction and nurse-assessed
Patients treated in hospitals with       were more likely to report that they    outcomes. The study was supported
high concentrations of black             were not confident patients would       in part by the Agency for
patients reported less satisfaction      be able to manage their care after      Healthcare Research and Quality
with their care and experienced          discharge. Nurses also reported         (HS18534).
several difficulties, reveals a new      more frequent complaints and            See “Quality of care and patient
study. The researchers examined          infections at hospitals with the        satisfaction in hospitals with high
patient discharge data from 568          highest percentage of black             concentrations of black patients,”
hospitals in California,                 patients. Nurse staffing was            by J. Margo Brooks-Carthon, Ph.D.,
Pennsylvania, New Jersey, and            significantly associated with three     R.N., Ann Kutney-Lee, Ph.D., R.N.,
Florida. They also surveyed nurses       outcomes: poor confidence in            Douglas M. Sloane, Ph.D., and
on their work environments,              discharge care capabilities, frequent   others in the Journal of Nursing
staffing levels, patient/family          patient/family complaints, and          Scholarship 43(3), pp. 301-310,
complaints, and the occurrence of        ventilator-associated pneumonia.        2011. I KB
adverse events, such as infections.

                                                                 Number 385, September 2012   17
Radionovela promotes awareness and knowledge of cervical cancer
vaccine among Hispanic parents
A short Spanish-language radionovela, a broadcast short       the HPV vaccine radionovela or to another public
story, can dramatically increase human papillomavirus         service announcement (PSA). The parents who heard
(HPV) vaccine awareness among rural Hispanic parents          the radionovela as part of a 15-minute broadcast of
of preteen and teenage daughters, concludes a new             other Spanish-language programming improved greatly
study. Hispanic women in the United States have a             in their awareness and knowledge of HPV vaccine
higher incidence of cervical cancer (primarily caused by      between a pretest and a posttest compared with parents
persistent, high-risk HPV infections) than white women.       who listened to another 5-minute Spanish-language
Following approval of the first anti-HPV vaccine              PSA about prostate cancer.
Gardasil® by the U.S. Food and Drug Administration in         Parents who heard the HPV vaccine radionovela were
2006 for females aged 9–26, it was expected that the          more likely than the control group to confirm that HPV
majority of cervical cancers could be prevented by            was a common infection (70 vs. 48 percent), to deny
vaccination of girls at the age of 11 or 12. Targeted         that women are able to detect whether they have HPV
programs are thought to be needed to target high-risk         infection (53 vs. 31 percent), to know the recommended
groups like Latino women.                                     age range for vaccination (87 vs. 68 percent), and to
Toward that end, the researchers tested a 5-minute            confirm that the vaccine is given in multiple doses. The
Spanish-language radionovela that includes a story            study was funded in part by the Agency for Healthcare
about a young girl who learns of the HPV vaccine from         Research and Quality (T32 HS13853).
a school friend and talks to her mother about it. Her         More details are in “Evaluation of a radionovela to
mother talks to a friend who is a nurse, the girl’s father,   promote HPV vaccine awareness and knowledge among
and a doctor about her interest and concerns about the        Hispanic parents,” by Deanna Kepka, Gloria D.
vaccine. After receiving consent from both her parents,       Coronado, Hector P. Rodriguez, and others in the
the young girl receives the vaccine from a local health       December 2011 Journal of Community Health 36(6),
clinic.                                                       pp. 957-965. I DIL
Rural Hispanic parents of daughters aged 9 to 17 (78
mothers and 10 fathers) were randomized to listen to

Comparative Effectiveness

Increased fluid and supplemental treatments may reduce recurrence of
kidney stones
Increased fluid intake, reduced soft       suggests that evidence is mixed on       Nephrolithiasis is the clinical term for
drink consumption, thiazide diuretics      whether dietary intervention             when hard masses form in the
(which lower urinary calcium               effectively reduces the risk of          kidneys. The new review, Recurrent
excretion and prevent calcium-             recurrent stones.                        Nephrolithiasis in Adults: A
containing kidney stones), citrate         Kidney stones may be present at any      Comparative Effectiveness Review of
pharmacotherapy (citrate naturally         age, but onset is more common in         Preventive Medical Strategies,
prevents kidney stone formation), and      young and middle-aged adults.            summarizes available evidence on the
allopurinol (used to treat excess uric     Lifetime prevalence is 13 percent for    effectiveness and risks of dietary and
acid in blood plasma) each decreased       men and 7 percent for women.             pharmacological preventive
the risk of recurrent calcium kidney       Following an initial onset of kidney     treatments. To access this review and
stones, according to a new research        stones, the 5-year recurrence rate in    other materials that explore the
review by the Agency for Healthcare        the absence of a specific treatment is   effectiveness and risks of treatment
Research and Quality’s (AHRQ’s)            between 35 to 50 percent. Direct         options for various conditions, visit
Effective Health Care Program. While       medical expenditures related to          AHRQ’s Effective Health Care
research data on kidney stones             kidney stones may exceed $4.5 billion    Program Web site at
remains limited, available research        annually in the United States.  I

18   Number 385, September 2012                                                  
    Agency News and Notes

 Clinician and patient resources now available on ADHD treatment options
 New patient and clinician summaries evaluating the         generally safe and effective for improving behavior.
 effectiveness of drug and behavioral treatments for        For both preschoolers and children over the age of 6,
 attention deficit hyperactivity disorder (ADHD) are        long-term effectiveness and adverse effects are not
 now available from the Effective Health Care Program       well studied.
 of the Agency for Healthcare Research and Quality          The patient summary and clinician summary are
 (AHRQ). ADHD is a disorder that affects about 5            accompanied by a continuing medical
 percent of children worldwide. Among preschool             education/continuing education activity and faculty
 children with disruptive behavior disorder (which          slide set to further assist clinicians, researchers, and
 includes ADHD), relatively strong evidence supports        other health professionals in decisionmaking. This set
 the effectiveness of several different types of parental   of resources is based on the research review, Attention
 behavior training. These low-risk treatments were          Deficit Hyperactivity Disorder: Effectiveness of
 found to provide benefits for at least 6 months, and up    Treatment in At-Risk Preschoolers; Long-Term
 to 2 years. Parents who attend more parental behavior      Effectiveness in All Ages; and Variability in
 training sessions see more improvement in their            Prevalence, Diagnosis, and Treatment.
 child’s behavior.
                                                            To access the summary and other materials that
 For children older than age 6, the report found low        explore the effectiveness and risks of treatment
 evidence that medications such as methylphenidate          options for various conditions, visit AHRQ’s Effective
 (sold under the trade name Ritalin®) and atomoxetine       Health Care Program Web site at
 (sold as Strattera®) used to treat ADHD symptoms are I


New AHRQ handbook helps practices implement interactive preventive
health records
A new handbook from the Agency          integrating IPHRs as components         into multiple and varied EHRs and
for Healthcare Research and             of electronic health records.           health care settings, and its
Quality (AHRQ) offers practical         The IPHR was developed and              integration into the primary care
guidance on the implementation of       studied in three AHRQ-funded            workflow for an entire practice’s
interactive preventive health records   projects to better understand how to    patient population.
(IPHRs). Based on the lessons           broadly implement and disseminate       One AHRQ-supported study,
learned from implementation of          patient-centered information            published in the Annals of Family
electronic health records (EHRs)        systems throughout primary              Medicine, found that IPHR users
from 3 different vendors at 14          care. These three projects build        were more likely to be up-to-date
different practices, the handbook       upon one another to show the            on all preventive services compared
provides practical steps for health     development and effect of the IPHR      with nonusers, especially in the
care professionals to follow when       tool on patient outcomes, the ability
                                        for it to be successfully adopted                     continued on page 20

                                                                 Number 385, September 2012    19
Preventive health records              future personal health records can     To Promote Prevention, visit
continued from page 19                 deliver higher levels of     
areas of screening tests and           functionality, similar to the IPHR,    Guide-0612.pdf. Visit
immunizations. It also showed that     and that a greater number of 
an IPHR and similar systems can        patients and clinicians actively use   pubmed/22778119 for the Annals of
improve important patient              the systems.                           Family Medicine abstract. For more
outcomes, such as the delivery of      To view the handbook, An               information on AHRQ’s IPHR
evidence-based preventive care. The    Interactive Preventive Care Record:    projects, go to
study authors recommended that         A Handbook for Using Patient-
more attention be paid to ensure       Centered Personal Health Records       KristSuccessStory2010.pdf. I

 AHRQ releases training modules to help improve the safety of nursing
 home residents
 The Agency for Healthcare Research and Quality            likely to be
 (AHRQ) has released a set of training modules to help     effective in
 educate nursing home staff on key patient safety          reducing
 concepts critical to improving the safety of nursing      medical errors
 home residents. The modules, Improving Patient            and improving
 Safety in Long-Term Care Facilities, include the          patient safety.
 following publications:                                   This approach
 • Detecting Change in a Resident’s Condition              can also help
                                                           reduce the
 • Communicating Change in a Resident’s Condition          number of falls
 • Falls Prevention and Management                         and fall-related
                                                           injuries at nursing homes. You can access the modules
 Each of the modules has an instructor’s guide and a       at I
 student workbook. Training of nursing home staff,
 including support for teamwork across specialties, is

20   Number 385, September 2012                                               
         Research Briefs

Anesetti-Rothermel, A., and            Chen, P.G., Curry, L.A., Nunez-          commonly performed. Yet the
Sambamoorthi, U. (2011).               Smith, M., and others. (2012,            independent prognostic
“Physical and mental illness           February). “Career satisfaction          implications of these markers have
burden: Disability days among          in primary care: A comparison of         not been previously compared by
working adults.” (AHRQ grant           international and U.S. Medical           AMI classification. The results of
HS15390). Population Health            graduates.” (AHRQ grant T32              this study indicate that both peak
Management 14(5), pp. 223-230.         HS17589). Journal for General            CK-MB and peak troponin have
Researchers measuring the impact       Internal Medicine 27(2), pp. 147-        independent incremental or additive
of 25 specific conditions on           152.                                     prognostic value among patients
disability days among working          The researchers found that among         treated for ST-segment elevation
adults found that the average          1,890 primary care physicians who        myocardial infarction and non-ST-
number of disability days varied       reported at least 20 hours per week      segment elevation myocardial
from 4 days for impulse-control        of direct patient care, international    infarction.
disorders to a maximum of 18 days      medical graduates (IMGs) were
for stroke. The contribution of        significantly less satisfied than U.S.
                                                                                Clancy, C.M. (2012). “Progress
coexisting conditions to disability    medical graduates (USMGs).
                                                                                on a national patient safety
days varied from 0 percent for         Seventy-six percent of IMGs
                                                                                imperative to eliminate
stroke and 14 percent for cancer to    reported satisfaction versus 82
                                                                                CLABSI.” American Journal of
72 percent for diabetes and 77         percent of USMGs. Lower
                                                                                Medical Quality 27(2), pp. 170-
percent for asthma.                    satisfaction was noted for IMGs
                                                                                171. Reprints (AHRQ
                                       who were solo practitioners (44
                                                                                Publication No. 12-R068) are
                                       percent lower) and those not in a
Chen, A., Schrager, S.M., and                                                   available from the Agency for
                                       practice that allowed the provision
Mangione-Smith, R. (2012).                                                      Healthcare Research and
                                       of high-quality care (56 percent
“Quality measures for primary                                                   Quality.*
care of complex pediatric                                                       The author, director of the Agency
patients.” (AHRQ grant                                                          for Healthcare Research and
HS18087). Pediatrics 129(3), pp.       Chin, C.T., Wang, T.Y., Shuang,          Quality, discusses a program to
433-445.                               L., and others. (2012).                  eliminate central line-associated
The goal of this study was to assess   “Comparison of the prognostic            bloodstream infections (CLABSIs).
through expert consensus               value of peak creatine kinase-MB         The Comprehensive Unit-based
recommended primary care               and troponin levels among                Safety Program, originally started
processes for complex pediatric        patients with acute myocardial           in Michigan intensive care units
patients by using the patient-         infarction: A report from the            (ICUs), was extended to hospitals
centered medical home approach as      Acute Coronary Treatment and             in 10 States. It has since been
a first step toward establishing a     Intervention Outcomes Network            expanded to hospitals nationwide,
candidate set of quality measures.     Registry—Get With The                    and to settings other than ICUs.
By using a systematic literature       Guidelines.” (AHRQ grant                 Other types of healthcare-
review and the RAND/University         HS16964). Clinical Cardiology            associated infections, besides
of California, Los Angeles             35(7), pp. 424-429.                      CLABSIs, are also included.
appropriateness method, a national     In patients with acute myocardial        Reports thus far have found
expert panel was able to select 35     infarction (AMI), serial                 considerable success in the
primary care quality measures for      measurements of both cardiac             reduction of infections.
complex pediatric patients.            troponin and creatine kinase MB
                                       isoenzyme (CK-MB) levels are                          continued on page 22

                                                                Number 385, September 2012    21
Research briefs                        Elbardissi, A.W., and Sundt, T.M.       The authors conducted a systematic
continued from page 21                 (2012). “Human factors and              review of the published literature
Crews, K.R., Gaedigk, A.,              operating room safety.” (AHRQ           describing potential nonfinancial
Dunnenberger, H.M., and others.        grant HS19190). Surgical Clinics        barriers to medication adherence
(2012, February). “Clinical            of North America 92, pp. 21-35.         among the elderly. They found that
pharmacogenetics                       This article reviews previous           the topic is not well described in
implementation consortium              research on the impact of work          the literature, despite being a major
(CPPIC) guidelines for codeine         system factors on surgical care.        cause of morbidity. Thus, it is
therapy in the context of              Specifically, the discussion            difficult to draw a systematic
cytochrome P4502D6 (CYP2D6)            highlights research pertaining to the   conclusion on potential barriers to
genotype.” (AHRQ grant                 following components of surgical        medication adherence among the
HS19818). Clinical Pharmacology        care: (1) the physical operating        elderly.
& Therapeutics 91(2), pp. 321-         room environment, (2) teamwork
326.                                   and communication, (3) tools and
The efficacy and safety of codeine                                             Glascock, J.J., Shababi, M., Wetz,
                                       technology, (4) tasks and workload,
as an analgesic are governed by                                                M.J., and others. (2012). “Direct
                                       and (5) organizational processes.
CYP2D6 polymorphisms. In order                                                 central nervous system delivery
to develop a guideline in this area,                                           provides enhanced protection
the authors conducted a systematic     Gartlehner, G., Poole, C., West,        following vector-mediated gene
literature review focusing on          S.L., and others. (2012). “Clinical     replacement in a severe model of
CYP2D6 and its relevance in            heterogeneity in systematic             spinal muscular atrophy.”
codeine use. The guideline provides    reviews and health technology           (AHRQ grant HS41584).
information relating to the            assessments: Synthesis of               Biochemical and Biophysical
interpretation of CYP2D6 genotype      guidance documents and the              Research Communications 417,
test results to guide the dosing of    literature.” (AHRQ Contract No.         pp. 376-381.
codeine.                               290-02-0016). International             This study was performed on mice
                                       Journal of Technology                   to directly compare the influence of
                                       Assessments in Health Care 28(1),       the injection route on the spinal
Dorn, S.D., Morris, C.B.,              pp. 36-43.                              muscular atrophy (SMA)
Schneck, S.E., and others. (2011).     This study summarizes a project to      phenotype. The researchers
“Development and validation of         identify, discuss, and synthesize       compared the two injection
the irritable bowel syndrome           best practices for addressing           techniques that have been used in
satisfaction with care scale.”         clinical heterogeneity in systematic    viral gene therapy of SMA:
(AHRQ grant HS19468). Clinical         reviews and health technology           intracerebroventricular and
Gastroenterology and Hepatology        assessments. Recognizing clinical       intravenous injections. Both routes
9, pp. 1065-1071.                      heterogeneity and clarifying its        resulted in a significant increase in
The authors used standard scale        implications helps decisionmakers       lifespan and weight compared to
development methods to develop         to identify patients who benefit        untreated mice.
the Irritable Bowel Syndrome           from an intervention or are at
Satisfaction with Care Scale (IBS-     greatest risk of an adverse outcome
SAT). They report the results of a                                             Halpern, S.D. (2011). “ICU
                                       from that intervention.
study to develop and assess the                                                capacity strain and the quality
psychometric properties of the IBS-                                            and allocation of critical care.”
SAT, including a conceptual and        Gellad, W.F., Grenard, J.L., and        (AHRQ grant HS18406). Current
measurement model (subscale            Marcum, Z.A. (2011). “A                 Opinions on Critical Care 17, pp.
structure), reliability (internal      systematic review of barriers to        648-657.
consistency), and validity (content,   medication adherence in the             The author presents a conceptual
convergent and discriminant            elderly: Looking beyond cost and        framework for intensive care unit
construct validity, and known-         regimen complexity.” (AHRQ              capacity strain, considers what data
groups validity).                      grant T32 HS00046). American            elements may contribute to it, and
                                       Journal of Geriatric
                                       Pharmacotherapy 9(1), pp. 11-23.                      continued on page 23

22   Number 385, September 2012                                                
Research briefs                         Kwon, S., Florence, M., Grigas, P,      Board of Family Medicine 25
continued from page 22                  and others. (2012). “Creating a         Suppl 1, p. S1. Reprints (AHRQ
suggests methods for determining        learning healthcare system in           Publication No. 12-R070) are
the optimal metric. He also outlines    surgery: Washington State’s             available from the Agency for
the range of potential consequences     Surgical Care and Outcomes              Healthcare Research and
of increased capacity strain, in        Assessment Program (SCOAP) at           Quality.*
terms of both the quality and ethics    5 years.” (AHRQ grant                   This article introduces a series of
of care delivered.                      HS20025). Surgery 151(2), pp.           reports from an international
                                        146-151.                                conference on primary care. Health
                                        SCOAP is a peer-to-peer                 policy, health system researchers,
Haukoos, J.S. (2012, January).
                                        collaborative that engages surgeons     and primary care leaders from
“The impact of nontargeted HIV
                                        to determine the many process-of-       seven countries, including the
screening in emergency
                                        care metrics that go into a “perfect”   United States, participated. Topics
departments and the ongoing
                                        operation, track risk-adjusted          included payment reform, team-
need for targeted strategies.”
                                        outcomes that are specific in a         based care, and the use of health
(AHRQ grant HS17526).
                                        given operation, and create             information technology to support
Archives of Internal Medicine
                                        interventions to correct                population management.
172(1), pp. 20-22.
                                        underperformance in both the use
The author examines this question
                                        of process measures and outcomes.
by analyzing 11 studies that have                                               Needleman, J., Buerhaus, P.,
                                        The authors discuss the progress of
systematically evaluated                                                        Pankratz, S., and others. (2011).
                                        the SCOAP initiative and highlight
nontargeted HIV screening in an                                                 “Nurse staffing and inpatient
                                        its achievements and challenges.
emergency department (ED)                                                       hospital mortality.” AHRQ grant
setting. He also discusses the                                                  HS15508. The New England
debate over targeted versus             Luft, H.S. (2012). “Advancing           Journal of Medicine 364(11), pp.
nontargeted HIV screening in the        public reporting through a new          1037-1045.
ED. He argues that targeted HIV         ‘aggregator’ to standardize data        Patients cared for by understaffed
screening most likely fails because     collection on providers’ cost and       shifts of registered nurses are
of poor implementation, not             quality.” (AHRQ Contract No.            slightly, but significantly, more
because targeting does not work.        290-07-10022). Health Affairs           likely to die while in the hospital
                                        31(3), pp. 619-626.                     than patients on fully staffed shifts,
                                        The author proposes creating a          found this study. Specifically,
Kramer, D.B., Xu, S., and
                                        public-private data aggregator that     patients on understaffed shifts were
Kesselheim, A.S. (2012, March).
                                        would receive patient and provider      2 percent more likely and patients
“Regulation of medical devices in
                                        data from payers that are               on high-turnover shifts were 4
the United States and European
                                        deidentified in such a way as to        percent more likely to die during
Union.” (AHRQ grant HS18465).
                                        remain useful for consumer              their hospital stay; both findings
New England Journal of Medicine
                                        reporting and research purposes. It     were significant.
366(9), pp. 848-855.
                                        could be funded through fees
Some policymakers and device
                                        charged to commercial users while
manufacturers have characterized                                                Neily, J., Mills, P.D., Eldridge, N.,
                                        registered researchers could access
U.S. device regulation as slow, risk-                                           and others. (2011). “Incorrect
                                        the data aggregator for free. Such
averse, and expensive, while others                                             surgical procedures within and
                                        an approach could allay privacy
have suggested that current                                                     outside of the operating room,”
                                        considerations as well as concerns
procedures may not be                                                           Archives of Surgery [Epub ahead
                                        about how such an effort would be
comprehensive enough. The authors                                               of print]. Reprints (AHRQ
compare the European Union and                                                  Publication No. 11-R076) are
U.S. systems and consider what                                                  available from AHRQ.*
evidence exists on the performance      Meyers, D. (2012, March).               To improve communication and
of each device-approval system.         “Introduction from the Agency           patient safety and reduce adverse
                                        for Healthcare Research and
                                        Quality.” Journal of the American                     continued on page 24

                                                                 Number 385, September 2012    23
Research briefs                        Improved hypertension care, that is,   pneumonia. The study compared
continued from page 23                 consistently providing the basic       the experience of Medicare fee-for-
events in the operating room, the      elements of blood pressure             service patients in 57 territorial
Veterans Health Administration         management to U.S. adults, would       hospitals and 4,799 stateside
implemented a mandatory medical        cost $170 more per person with         hospitals.
team training program between          hypertension each year, estimates
2006 and 2009. This training           this study. These costs are affected
includes preoperative briefings and                                           Olfson, M., Crystal, S., Gerhard,
                                       by the cost of medication per day,
postoperative debriefings, both                                               T., and others. (2011). “Patterns
                                       the optimal number of visits for
guided by a checklist. Researchers                                            and correlates of tic disorder
                                       recommended care, the blood
found the rate of reported adverse                                            diagnoses in privately and
                                       pressure elevation, and the
events declined from 3.21 per                                                 publicly insured youth. (AHRQ
                                       complexity of the hypertension
month from 2001 to mid-2006 to                                                grant HS16097). Journal of the
2.4 per month from mid-2006 to                                                American Academy of Child and
2009.                                                                         Adolescent Psychiatry 50(2), pp.
                                       Nuckols, T.K., McGlynn, E.A.,          119-131.
                                       Adams, J., and others. (2011).         Medicaid-insured children
Noël, P.H., Lanham, H.J.,              “Cost implications to health care      diagnosed with Tourette disorder
Parchman, M.L., and others.            payers of improving glucose            (often characterized by severe vocal
(2012, March). “The importance         management among adults with           and physical tics) tend to have more
of relational coordination and         type 2 diabetes” (AHRQ grant           psychiatric and behavioral problems
reciprocal learning for chronic        HS17954). HSR: Health Services         than similar children with private
illness care within primary care       Research 46(4), pp. 1158-1179.         insurance. This study finds that
teams.” Health Care Management         This study reveals that the cost of    they also appear to be diagnosed at
Review [Epub ahead of print].          providing improved glucose             a later stage and receive more
Reprints (AHRQ Publication No.         management, relative to current        antipsychotic medications and less
12-R053) are available from            care, would be $327 per person         mental health assessments or
AHRQ.*                                 annually, with the increased cost      psychotherapy than their privately
Researchers recently explored how      largely due to antihyperglycemic       insured counterparts.
primary care team members              medication. Researchers found that
perceive their relationships and       the cost-effectiveness to payers,
learning as they relate to Chronic                                            Pakyz, A., Carroll, N.V., Harpe,
                                       defined as the incremental annual
Care Model (CCM) success. They                                                S.E., and others. (2011).
                                       costs per patient newly attaining
found that high levels of relational                                          “Economic impact of Clostridium
                                       any one of three care goals, would
coordination were significantly and                                           difficile infection in a
                                       be $1,128; including glycemic
positively associated with the                                                multihospital cohort of academic
                                       crises reduced this to $555.
delivery of care as described by the                                          health centers.” (AHRQ grant
CCM model. Reciprocal learning                                                HS18578). Pharmacotherapy
was also found to be independently     Nunez-Smith, M., Bradley, E.H.,        31(6), pp. 546-551.
and significantly associated with      Herrin, J., and others. (2011).        Patients with healthcare-associated
fulfilling all six elements of the     “Quality of care in U.S.               Clostridium difficile infections
CCM.                                   Territories.” Archives of Internal     (CDIs) have an adjusted mean cost
                                       Medicine, pp. E1-E13. [Epub            of hospital care nearly double that
                                       ahead of print].                       for matched patients without CDI
Nuckols, T.K., Aledort, J.E.,          A comparison of hospitals in U.S.      ($55,769 vs. $28,609), found this
Adams, J., and others. (2011).         Territories to hospitals in U.S.       study of administrative data. The
“Cost implications of improving        States finds that patients in          researchers also found in their
blood pressure management              territorial hospitals experience       case–control study that the adjusted
among U.S. adults.” (AHRQ              significantly higher 30-day            mean length of hospital stay was
grant HS17954.) HSR: Health            readmission rates and higher           more than twice as long (21.1 days)
Services Research 46(4), pp. 1124-     mortality rates for acute myocardial   for patients with healthcare-
1157.                                  infarction, heart failure, and
                                                                                           continued on page 25

24   Number 385, September 2012                                               
Research briefs                         Pitzer, V.E., Burgner, D., Viboud,     patients.
continued from page 24                  and others. (2012, March).
associated CDI than for those           “Modeling seasonal variations in
without the infection (10.0 days).                                             Rosolowsky, E.T., Skupien, J.,
                                        the age and incidence of
                                                                               Smiles, A.M., and others. (2011).
                                        Kawasaki disease to explore
                                                                               “Risk for ESRD in Type 1
                                        possible infectious etiologies.”
Peron, E.P., Marcum, Z.A.,                                                     diabetes remains high despite
                                        Proceedings of the Royal Society
Boyce, R., and others. (2012,                                                  renoprotection.” (AHRQ grant
                                        of Biological Sciences [Epub
February). “Year in review:                                                    T32 HS00063) Journal of the
                                        ahead of print]. Reprints
Medication mishaps in the                                                      American Society of Nephrology
                                        (AHRQ Publication No. 12-
elderly.” (AHRQ grants                                                         22(3), pp. 545-553.
                                        R071) are available from
HS17695, HS18271, HS19461).                                                    Treating patients who have type-1
American Journal of Geriatric                                                  diabetes and high urine albumin
                                        The average age of Kawasaki
Pharmacotherapy 9(1), pp. 1-10.                                                levels with kidney-protective
                                        disease infection is expected to
This paper reviewed 5 articles from                                            medications and blood-pressure
                                        vary during seasonal epidemics in
2010 that examined medication                                                  lowering medications does not
                                        a way that is predictable from the
mishaps in the elderly. Three                                                  reduce the risk of their developing
                                        epidemiological features. To
studies focused on types of                                                    end-stage renal disease (ESRD),
                                        determine whether examining the
medication errors, including                                                   concludes a new study. Despite
                                        relationship between seasonal
underuse due to prescribing and                                                treatments meant to prevent the
                                        variation in the number and
potentially inappropriate                                                      condition’s development, 172 of
                                        average age of cases can lend
prescribing. The other studies                                                 423 study patients developed
                                        insight into the number of
focused on medication-related                                                  ESRD, 62 of whom died during
                                        infectious triggers, the researchers
adverse patient events related to the                                          dialysis.
                                        sought to extend and validate
use of skeletal muscle relaxants
                                        previous work on age-incidence
and high-risk medications.
                                        patterns, then apply this theory to    Ruhnke, G.W., Coca-Perraillon,
                                        Kawasaki disease.                      M., Kitch, B.T., and Cutler, D.M.
Phillips, R.L. (2012).                                                         (2011) “Marked reduction in 30-
“International learning on                                                     day mortality among elderly
                                        Quattromani, E., Powell, E.S.,
increasing the value and                                                       patients with community-
                                        Khare, R.K., and others. (2011).
effectiveness of primary care (I                                               acquired pneumonia,” (AHRQ
                                        “Hospital-reported data on the
LIVE PC).” (AHRQ Contract                                                      grant HS16948). American
                                        pneumonia quality measure
No. 290-07-10008). Journal of the                                              Journal of Medicine 124, pp. 171-
                                        ‘time to first antibiotic dose’ are
American Board of Family                                                       178.
                                        not associated with inpatient
Medicine 25 Suppl 1, pp. S2-S5.                                                Deaths from community-acquired
                                        mortality: Results of a
This article provides a brief                                                  pneumonia, the most common
                                        nationwide cross-sectional
introduction to eight papers from                                              infectious cause of death in the
                                        analysis.” (AHRQ grant T32
an international conference on                                                 United States, dropped 28 percent
                                        HS00078). Academic Emergency
primary care funded in part by the                                             from 1987 to 2005, according to
                                        Medicine 18(5), pp. 496-503.
Agency for Healthcare Research                                                 this study. It found that 30-day
                                        Hospitals are required to publicly
and Quality. The countries                                                     mortality from this condition
                                        report on their quality measures for
represented were Australia,                                                    dropped from 13.5 percent to 9.7
                                        treating pneumonia, including the
Canada, Denmark, The                                                           percent. The researchers believe
                                        time to first antibiotic dose
Netherlands, New Zealand, the                                                  that increased pneumococcal and
                                        (TFAD). This means that hospitals
United Kingdom, and the United                                                 influenza vaccination rates, as well
                                        must give the first antibiotic dose
States. Topics discussed include                                               as a wider use of antibiotics, may
                                        within 6 hours after a patient
new models of care, accountability                                             explain a large portion of the
                                        arrives at the hospital. In fact, a
and population health, practice                                                downward trend in mortality.
                                        new study finds no association
support and change facilitation,
                                        between this TFAD quality measure                    continued on page 26
and care quality and safety.
                                        and inpatient mortality for these

                                                                 Number 385, September 2012   25
Research briefs                         Spindler, K.P., Huston, L.J.,          Steinman, M.A., Hanlon, J.T.,
continued from page 25                  Wright, R.W., and others. (2011).      Sloane, R.J., and others. (2011).
Sarkar, U., Karter, A.J., Lieu,         “The prognosis and predictors of       “Do geriatric conditions increase
J.Y., and others. (2011). “Social       sports function and activity at        risk of adverse drug reactions in
disparities in internet patient         minimum 6 years after anterior         ambulatory elders? Results from
portal use in diabetes: Evidence        cruciate ligament reconstruction.      the VA GEM Drug Study.”
that the digital divide extends         A population cohort study.”            (AHRQ grant HS17695 and
beyond access.” (AHRQ grants            (AHRQ grant HS16075).                  HS18721). Journal of
HS17594 and HS17261). Journal           American Journal of Sports             Gerontology. Series A. Biological
of the American Medical                 Medicine 39(2), pp. 348-359.           Sciences and Medical Sciences
Informatics Association 18, pp.         Tears in the ACL (anterior cruciate    66A(4), pp. 444-451.
318-321.                                ligament), a major ligament of the     Common geriatric conditions do
Internet portals allow patients to      knee, are common, especially           not significantly increase the risk of
conduct a variety of tasks normally     among athletes. This study             adverse drug reactions (ADRs),
associated with an office visit, such   identifies factors that help predict   according to a new study by
as refilling prescriptions and          better or worse functional outcomes    researchers at three Veterans Affairs
communicating with providers.           following ACL reconstruction. Use      (VA) medical centers. Using data
Studies have shown poor outcomes        of the patient’s own tissue            from an ongoing VA study, the
among minority and less educated        (autograft) rather than tissue from    researchers found only weak
patients. This study finds that these   another person (allograft), not        associations between either
groups also experience a “digital       smoking, and having normal body        mobility impairment or dependency
divide,” making them less likely to     mass index were correlated with        in activities of daily living and
have access to these Web portals        better long-term outcomes.             ADRs. I
and their disease-management

26   Number 385, September 2012                                                
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September 2012
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